HealthcarePapers
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In this paper, we review recent developments in the debate over the role of the private sector in healthcare in Canada, with a particular focus on the two major federal reports that were released in the autumn of 2002, the final report of the Senate Committee on Social Affairs (the Kirby report ) and the Romanow Commission report. It is possible to see these reports as representing two polarized positions in the public versus private debate. Kirby has often been portrayed as an advocate of privatization whereas Romanow has been given the role of champion of the public system. ⋯ This allows us to draw some provisional conclusions on the degree of consensus that prevails in the healthcare debate, and on the sources of pressure for change. Given the universal emphasis currently placed on the need to base policy conclusions on "evidence," we also look at some recent academic contributions to the debate, notably by Raisa Deber and Devereaux et al., in order to better understand what the best available evidence indicates about the merit of the various forms of healthcare delivery. As well, we examine examples of private delivery of health services, including the Morgentaler clinics, that point to the importance of retaining the space for experimentation with forms of delivery that currently exists within the Canadian healthcare system.
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Outside hospitals, drug therapy is not universally insured by the Canadian public health care system. Coverage depends on choices made by the provincial and territorial governments in designing their pharmacare programs. A priority within the programs is ensuring that all Canadians have reasonable access to catastrophic drug coverage. ⋯ This commentary reviews evidence and experience from other countries in order to assess the options for a few key dimensions of expanding pharmacare coverage. These are: eligibility rules for individual coverage; drug assessment in terms of approval for coverage; medication management strategies; and finally ongoing program evaluation. Catastrophic drug coverage needs to be flexible to adapt to existing pharmacare programs and responsive to the competing demands for limited resources within the health care sector.
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Canada's public-private mix in coverage for pharmaceuticals has long created variation across provinces in access to needed treatments and has contributed to persistent cost growth in both the private and public sectors. Among the recommendations of the 2002 Romanow Commission was a proposed national standard for "last-dollar" pharmacare that would cover any household's drug costs beyond a high annual deductible. Such a program contrasts with the "first-dollar" pharmacare programs currently available for vulnerable populations (e.g., seniors and social assistance recipients) in most provinces. While last-dollar coverage may be a valuable set toward broadening public pharmacare in Canada, there is a risk that provincial governments may interpret the coverage of catastrophic costs as the new pharmacare ideal and therefore reduce or eliminate existing programs that currently offer first-dollar benefits.
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In Healing Medicare, Michael Decter (1994) quotes from a speech made in 1982 by Tommy Douglas: "When we began to plan medicare (35 years previously), we pointed out that it would be in two phases. The first phase would be to remove the financial barrier between those giving the service and those receiving it. The second phase would be to reorganize and revamp the delivery system--and of course, that's the big item. It's the big thing we haven't done yet."
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Howard Chodos and Jeffrey MacLeod offer a breath of fresh air, with their call for a pragmatic approach to decisions about the role of the private sector in the Canadian healthcare system. At the current rate of growth, Canadians will spend 125 billion Canadian dollars on health services this year. We have some decisions to make: the healthcare system is too big, too complex and too important for us to make those decisions based on preconceived notions or ideology.